Central Sierra 4-H Facilities Use Agreement Request: CLUB/COUNTY EVENTS

✻ = Required

Event Title: ✻

Club/Program Name: ✻

Event Contact Person: ✻

Event Contact Email: ✻

Contact Phone: ✻

Do you want your phone published for the event contact: ✻

Yes No

FACILITY INFORMATION

Contact the facility you wish to use, set dates, determine the cost, and see if they will require a Certificate of Insurance. Some facilities may require a facility use agreement or an application.

DO NOT SIGN AGREEMENTS or APPLICATIONS

If either is required, the contract or application should name 'The Regents of the University of California' as the licensor. It must be reviewed and signed by the County Director. If you sign a contract or application you are personally responsible, not the University

Please attach the Facility Use Agreement at the bottom of this form.

If only a paper copy is available, you may mail it to the 4-H Office.

Amador & El Dorado: 311 Fair Lane, Placerville, CA 95667

Calaveras & Tuolumne: 2 South Green Street, Sonora, CA 95370

Does this facility have their own Facility Use Agreement? ✻

Yes No

Does this facility require a Certificate of Self-Insurance Coverage? ✻

Yes No

EVENT INFORMATION

If a contract was mailed, enter date:

Facility/Agency Name: ✻

Facility Physical Address: ✻

City/Zip ✻

Facility Mailing Address (If different from physical):

Facility Contact Person Name: ✻

Facility Contact Phone: ✻

Facility Contact E-MAIL: ✻

THE FOLLOWING INFORMATION IS OFTEN REQUIRED BY FACILITIES

Event Date: ✻

Event Start Time: ✻

Event End Time: ✻

Event Set-Up Time: ✻

Event Departure Time (after clean-up): ✻

Is the event open to the public ✻

Yes No

Will an admission fee be charged? ✻

Yes No

Approximately how many adults are expected? ✻

Approximately how many youth are expected ✻

Room(s) requested: (include kitchen if needed) ✻

On-Site furniture/equipment needed (Chairs, Tables, PA system, etc.) ✻

Will you need the facility to set-up any equipment? ✻

Yes No

If YES, please specify:

Will you be serving food at the event? ✻

Yes No

If YES, please mark all that apply:

Prepackaged Prepared in advance Prepared on-site

If Prepared on-site, please describe what you will be serving:

Please note additional information may be requested.

ADDITIONAL INFORMATION about EVENT

Is Registration required? ✻

Yes No

If YES, please specify DUE DATE:

If YES, Please specify location to submit registration (On-line, 4-H Office, other)

Registration/Participation Fee (if a fee, please specify) ✻

Will there be a fundraiser at this event: ✻

Yes No

STATUS (to be completed UCCE staff only):

If YES, 4-H Office approval is REQUIRED BEFORE advertising the event.

Have you already submitted Form 8.7 Fundraising Approval Request to the 4-H office?

Yes No

Please provide basic information about this event, such as activities, speakers, participants, topics, etc. (This information will be used in the newsletter and website if applicable)

Any additional registration form(s)/packet(s) will need to be submitted to the 4-H office for approval and required additions by UC ANR. If you provide the needed information, the 4-H office can format them for your event.

Would you need to have a registration form/packet posted to the website for members to download?

Yes No

Additional notes:

If you have a contract, agreement and/or application to submit, please use the upload option below.

Also, please upload any flyers or registration forms for your event.

Thank you.

Upload your file(s)